Patient Returns: A Complete Guide to Getting Started
Everything published so far — in reading order
If you’ve just found this Substack, welcome.
If you’ve been following along but missed a few posts, this is your catch-up.
This article is a summary and reading guide for everything published on Patient Returns so far. It’s written for NHS staff who want to start making calm, sensible financial decisions, without hype, jargon, or constant monitoring.
Each section below summarises a published article and links to the full version. They’re arranged in the order I’d recommend reading them if you’re starting from scratch.
1. Why this Substack exists (and who it is for)
Patient Returns exists because most NHS staff are too busy, and too tired, to spend hours learning about personal finance. But that doesn’t mean it should be ignored.
This Substack is for NHS staff who want to make better financial decisions without the noise. No hype& no jargon (or a little jargon explained!).
The goal is stability, clarity, and calm.
2. A low-effort financial setup for busy NHS staff
This is the foundational article. Before thinking about investing, you need a simple financial structure that runs quietly in the background.
The setup has five steps:
Make day-to-day money boring: one main account for bills, one for spending. No mental arithmetic.
Build an emergency buffer: a few months of essential spending in cash. This buys peace of mind.
Let the NHS pension do the heavy lifting: it provides guaranteed, inflation-protected income for life. It’s your base layer.
Simple investing, only when appropriate: a stocks and shares ISA with broad, diversified funds and automated contributions.
Automate everything: contributions, bills, decisions. If it requires constant attention, it won’t survive a difficult rota.
The philosophy: boring and robust beats clever and fragile.
3. Compounding money over time: the rule of 72
One of the simplest and most powerful ideas in personal finance.
Divide 72 by your annual rate of return. The result is roughly how many years it takes your money to double.
At 6%, money doubles every ~12 years
At 9%, every ~8 years
Inflation at 3% halves your spending power in ~24 years
The rule of 72 shows that time does the heavy lifting. Starting earlier matters more than picking the “best” investment. It also reveals why cash sitting in a low-rate account is quietly losing value, doing nothing is a decision.
The article includes a worked example using a child’s investment account to show how powerful compounding becomes over a full lifetime.
4. The risk-free rate: what it means and why you should know about it
The risk-free rate answers a simple question: what return can I expect without taking meaningful risk?
In the UK, the answer is the yield on government bonds (called gilts). These are backed by the government and are as close to “safe” as markets get.
At the time of writing, short-term gilts yield roughly 3.5–4%, and longer-dated gilts yield around 5%. These numbers form the baseline against which every other investment should be judged.
If a risky investment doesn’t expect to return meaningfully more than the risk-free rate, it may not be worth the stress.
This concept also helps explain why cash isn’t truly “risk-free” over the long term, inflation quietly erodes its purchasing power.
5. Financial risk management: “Heads I win, tails I don’t lose very much”
Borrowed from investor Mohnish Pabrai’s The Dhandho Investor, this framework asks two questions before committing money to anything:
What’s the realistic upside if it goes well?
What’s the realistic downside if I’m wrong?
Good decisions have asymmetric outcomes; you can gain much more than you risk. Most people focus entirely on upside. Many clinical staff do the opposite, focusing entirely on downside, because that’s what clinical training rewards.
The key insight: volatility is not risk. Prices moving up and down is uncomfortable, but discomfort is not the same as danger. Real risk is permanent loss of capital, or being forced to sell at the wrong time.
NHS workers are notorious risk avoiders. That protects patients, but it can lead to avoiding investing altogether, letting inflation silently eat away at savings.
6. Margin of safety: why it matters more than being right
Originating with Benjamin Graham and refined by Warren Buffett and Charlie Munger, margin of safety means building decisions so that if you’re wrong, the consequences are limited.
In investing, it means paying less than something is worth and allowing room for error. More broadly, it means avoiding situations where one mistake is fatal; avoiding fragility.
The article includes a personal example of buying Uber shares at around $90 with little margin of safety, and how that felt when the price dropped. Haste and emotion erode margin of safety quickly.
For passive investors, margin of safety shows up as broad diversification, low costs, and long time horizons. The NHS pension is margin of safety in action, guaranteed income, inflation protection, no market timing required. ISAs add optionality, which is another form of margin of safety applied to life.
As the article puts it: margin of safety is clinical reasoning applied to money.
7. Passive investing: the calm way to grow your money
If there’s one approach that works for most busy NHS staff, it’s passive investing. It means buying broad market index funds, holding them long-term, and reinvesting dividends, rather than trying to pick stocks or time the market.
It works because markets tend to rise over time, diversification reduces risk, costs are low, and compounding does the work quietly.
Active investing can work for some people, but it requires time, skill, and emotional control; things busy NHS staff often can’t spare. Passive investing avoids stress over daily market moves, overtrading, and chasing headlines.
The article also notes that passive investing isn’t “doing nothing.” It’s doing the right thing consistently, complementing the NHS pension and emergency cash reserves.
8. Understanding bonds: government, corporate, and how to value them
Bonds are loans you make to a government or a company in return for interest payments. They’re less volatile than shares and serve as a key building block of a balanced portfolio.
UK government bonds (gilts) are very low risk and form the benchmark “risk-free” rate. Their value depends on the coupon rate, market yield, and time to maturity.
Corporate bonds carry more risk because companies can default, but they compensate with higher expected returns. The difference between a corporate bond yield and the gilt yield is the credit spread, the premium for taking on that extra risk.
Longer-dated bonds are more sensitive to interest rate changes. For NHS staff, bonds complement pensions, ISAs, and passive equity funds by reducing overall portfolio volatility.
9. Price to earnings (P/E): a useful shortcut, not a crystal ball
P/E is one of the most common numbers you’ll see when looking at stocks. It simply tells you how much investors are willing to pay for £1 of a company’s current earnings.
A high P/E usually means high growth expectations. A low P/E usually means low expectations or perceived risk. It’s a useful first-pass filter; but dangerous if used alone, because earnings are not fixed.
P/E is especially misleading for cyclical businesses, where peak earnings make the ratio look artificially low just before profits collapse.
Importantly, passive investors don’t need to act on P/E at all. The edge in passive investing comes from low costs, diversification, and time - not valuation judgements. The article compares P/E to a blood test: informative, incomplete, and never interpreted in isolation.
10. How to understand an ETF (without overcomplicating it)
An ETF (Exchange Traded Fund) is simply a fund that trades on a stock exchange like a share. It’s a wrapper; the important thing is what’s inside it.
The article walks through how to read an ETF properly: what index it tracks, accumulating vs distributing, the ongoing charges figure (OCF), physical vs synthetic replication, fund size, tracking difference, domicile, and bid-offer spread.
For long-term passive investors, the things that actually matter are the index, cost, accumulation type, and fund size. Everything else is secondary.
The biggest mistake isn’t picking the wrong ETF. It’s overcomplicating things, changing strategy repeatedly, or switching after downturns. ETF selection is a one-hour decision. Sticking with it is the real work.
11. Setting up a stocks and shares ISA with Hargreaves Lansdown
The most common request from colleagues: “Can you help me set up an account?”
This is a practical, step-by-step guide to opening a stocks and shares ISA with Hargreaves Lansdown (other providers exist). It covers what you’ll need beforehand, how to navigate the sign-up process, what the disclaimers mean, how to fund the account, and the important choice between accumulating and distributing income.
The key advice: have your details ready, understand the ISA rules (£20,000 annual limit across all ISA types), be free from significant debt, and choose “automatically reinvested” for income if you want a low-effort setup.
12. NHS Pension Part 1: How the NHS Pension Is Actually Calculated
Most NHS staff contribute to their pension every month. Very few understand how it’s calculated.
The current scheme (2015) is a Career Average Revalued Earnings (CARE) scheme; not a final salary scheme. Each year, you earn 1/54th of your pensionable pay as a slice of future pension income. That slice then increases every year by CPI + 1.5% until retirement.
A worked example: if you earn £54,000 in a year, you earn £1,000 per year of guaranteed retirement income; for life, inflation-protected, backed by the government. Over 30 years with salary progression and revaluation, this adds up substantially.
There is no visible investment pot, no market risk, no sequence-of-returns risk. Instead: guaranteed income, inflation linkage, and longevity protection. That security is expensive to replicate privately - which is why understanding it changes how you invest outside it.
13. NHS Pensions Part 2: How to Access and Understand Your Total Reward Statement
Now that you understand how the pension is built, this article shows you where to see it.
Your Total Reward Statement (TRS) is accessed via the Electronic Staff Record (ESR) portal. It shows what you’ve built so far, your projected pension, lump sum information, and death-in-service benefits.
The article walks through how to log in, navigate to the pension section, and interpret the numbers, including the difference between standard benefits (no lump sum) and the option to exchange pension for a tax-free lump sum at retirement.
It also explains the pensionable earnings statement, which shows your yearly earnings and pension earned in each year of the scheme.
If you haven’t checked your TRS before, this is a good prompt to do so.
Suggested reading order
If you’re starting from zero, here’s the order I’d suggest:
Why this Substack exists: context and philosophy
A low-effort financial setup: the overall framework
The rule of 72: why time matters
The risk-free rate: your baseline for comparison
Risk management and Margin of safety: how to think about risk
Passive investing: the approach that works for most people
Understanding bonds: an important asset class
P/E ratio and ETFs: tools for understanding what you’re buying
Setting up an ISA: the practical how-to
NHS Pension Parts 1 & 2: understanding what you already have
A final thought
You don’t need to read everything at once. Pick what’s relevant to you right now and come back to the rest later.
The whole point of Patient Returns is that good financial outcomes come from calm, sensible decisions; repeated over time.
Not from urgency. Not from complexity. Not from cleverness.
From patience.
This article is for educational purposes only and does not constitute financial advice. Please consult a qualified financial adviser for decisions specific to your circumstances.